CUES

SUBJECTIVE:
Mga tolo og
upat ka oras
lang ko
nakatuwog
kai dile ko
ganahan
mutuwog
dire. as
verbalized by
the client.
Dili ko
makatuwog
og maayo kai
dile man
muundan ang
ila pagsaba
saba. as
verbalized by
the client.
Dili ko
ganahan
mutuwog dire
kai dli man
jud maayo an
ang ila
kama. as
verbalized by
the client.
OBJECTIVE:
Verbal
complai
nts of
difficult
y of
falling
asleep.
Verbal
complai
nts of
feeling
not well
rested.
Dark
creases
surroun
ding
eyes.
Drowsy

NURSING
DIAGNO
SIS
Disturbe
d sleep
pattern
related
to
environ
mental
factors
such as:
tempera
ture,
noise,
kinds of
beddings
.

SCIENTIFIC
RATIONALE

EXPECTED
OUTCOMES

Environmen
t can
promote or
hinder
sleep. Any
change- for
example,
noise in the
environment
- can inhibit
sleep. The
absence of
usual stimuli
can prevent
people from
falling
asleep.
Discomfort
from
environment
al
temperature
and lack of
ventilation
can affect
sleep.
Another
influence
includes the
comfort of
the bed. A
persons
partner who
has different
sleep habits,
snores, or
has other
sleep
difficulties
may
become a
problem for
the person
also.

Short-term:
After 4
hours of
nursing
intervention
s, the client
will be able
to:
GENERAL:
* identify
factors
influencing
sleep
disturbance
SPECIFIC:
* identify
personal
habits that
disrupt
sleep
pattern.
* identify
other issues
that might
need
attention.

SOURCE:
Fundamenta
ls of Nursing
Practice8th
edition
Volume 2
by Kozier
and Erb

Long-Term:
After 5 days
of nursing
intervention
s, the client
will be able
to:
GENERAL:
* develop a
sleeping
pattern that
provides
sufficient
energy for
daily
activities.
SPECIFIC:
* improve
quality and
quantity of
sleep.
* enhance
sleep
pattern by
using
relaxation

NURSING
INTERVENTION
S
INDEPENDENT:
1. Assess
clients usual
sleep pattern,
any changes
that occurred,
and what was
happening at
the time.
2. Develop a
sleep relaxation
program with
client such as
muscle
relaxation and
imagery.

3. Demonstrate
and rehearse
these
techniques with
client until
client feels
relaxed and is
able to practice
them at
bedtime.

4. Encourage
client to
simultaneously
work on any
issues that
might be
adversely
affecting sleep.
Offer referrals
when
appropriate.

COLLABORATIV
E:
1. Establish

RATIONALE

EVALUATIO
N

1.
Information
from both
client and
family
clarifies
specific
sleep
disturbance.

SHORT
TERM
GOALS
MET as
evidenced
that the
client:
*Identified
factors
influencing
sleep
disturbanc
e
*Identified
personal
habits that
disrupt
sleep.
Identified
issues that
might
need
attention
*Identified
other
issues that
might
need
attention.

2.
Employing
both
physical and
mental
relaxation
can help
minimize
anxiety and
promote
sleep.
3. Have
client
practice
chosen
relaxation
method with
nurse. Allow
time for
client to
begin to feel
results of
relaxation.
4.
Disturbance
s in sleep
are often
secondary
to issues
either
emotional or
physical. If
such issues
are present,
they need to
be
addressed.

LONG
TERM
GOALS
MET as
evidenced
that the
client:
*
Developed
a sleeping
pattern
that
provides
sufficient
energy for
daily
activities.
* Improved
quality
and
quantity of
sleep.

while
talking
to
student
nurse
Noisy
environ
ment
upon
enterin
g to
ward
Slightly
hot
temper
ature in
the
part of
ward
where
patient
is
resting
No
beddin
gs nor
mattres
ses
present
on the
ward

(p.1170)

exercises.

with client a
sleep program
that
incorporates
that
incorporates
the elements of
good sleep
hygiene and
relaxation
tools.

1. Client is
more likely
to follow
plan if he/
she is
involved
with the
incorporatio
n of known
effective
techniques.

2. Administer
sedatives if
ordered.

2. Helps
alleviate
symptoms
of sleep
disturbance.

3. Encourage
client to:
* Use
decaffeinated
beverages.
* Limit fluid
intake 3 to 5
hours before
retiring.
* Establish
regular times of
retiring and
waking.

3. These are
known
sleeping
aids.

*
Enhanced
sleep
pattern by
using
relaxation
exercises.